PHOENIX PREFERRED CARE
CLIENT REFERRAL FORM
Date of Referral
*
-
Month
-
Day
Year
Date
Person Completing Form
*
Person Providing Info
*
REFERRAL REGION
*
Pulaski/Somerset
McCreary/Whitley City
Wayne/Monticello
Jefferson/Louisville Metro
Telehealth/Statewide
Other
DEMOGRAPHIC INFORMATION (OF CLIENT/PERSON SEEKING SERVICES)
Full Legal Name *Note: As listed on ID/insurance
*
Other Names Client Goes By (if different)
DOB
*
-
Month
-
Day
Year
Date
Age
SSN
Sex (Assigned At Birth)
*
Male
Female
Gender Identity
Male
Female
Other
Race
Religion
Pronouns
He/him
She/her
They/them
Other
CONTACT INFORMATION
Mailing Address
*
Phone #
*
Format: (000) 000-0000.
Physical Address (if different from mailing)
E-mail Address
*
example@example.com
Parent/Guardian Name(s)
Relationship
Guardian Phone
Format: (000) 000-0000.
Emergency Contact Name
Emergency Contact Phone
Format: (000) 000-0000.
Primary Care Physician (PCP)
*
PCP Phone #
Format: (000) 000-0000.
PCP Address
INSURANCE INFORMATION
Medicaid ID (MAID), if applicable
PRIMARY INSURANCE Insurance Provider/ MCO
*
Name of Insured Person
Policy #/MCO ID
*
Group #
SECONDARY INSURANCE (if applicable) Insurance Provider/ MCO
Name of Insured Person
Policy #/MCO ID
Group #
RESPONSIBLE PARTY INFORMATION
Name
Relationship
DOB
-
Month
-
Day
Year
Date
Gender
Address
Phone #
Format: (000) 000-0000.
REFERRAL INFORMATION
Referral Source/ How did you hear about us?
Phone #
Format: (000) 000-0000.
Reason for Referral/Presenting Problem
Notice: Submitting this form is not a guarantee of an appointment. If you have any questions, please call us at (606) 451-9379. For additional information regarding services offered by Phoenix Preferred or to schedule an intake appointment, contact Intake Coordinator (Shana Rose, BS) at shanaroseppc@gmail.com or (606) 451-9379
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